Does Hospital Price Competition Influence Nurse Staffing and Quality of Care? - PowerPoint PPT Presentation

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Does Hospital Price Competition Influence Nurse Staffing and Quality of Care?

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Does Hospital Price Competition Influence Nurse Staffing and Quality of Care? Julie Sochalski, PhD1 R. Tamara Konetzka, PhD2 Jingsan Zhu, MBA1 Joanne Spetz, PhD3 – PowerPoint PPT presentation

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Title: Does Hospital Price Competition Influence Nurse Staffing and Quality of Care?


1
Does Hospital Price Competition Influence Nurse
Staffing and Quality of Care?
  • Julie Sochalski, PhD1
  • R. Tamara Konetzka, PhD2
  • Jingsan Zhu, MBA1
  • Joanne Spetz, PhD3
  • Kevin Volpp, MD, PhD1,4
  • Academy Health
  • June, 2005
  • 1 University of Pennsylvania 2 University of
    Chicago
  • 3 University of California at San Francisco 4
    Philadelphia VA Medical Center

2
Introduction
  • Over past 20 years hospitals shift from competing
    on quality/amenities competing on price.
  • Evidence that price competition rate of
    increase in hospital costs, profits
    efficiencies or lower quality?
  • Examine impact of price competition on one
    feature associated with hospital quality nurse
    staffing.

3
Nurse Staffing Patient Outcomes Relationship
  • Cross-sectional studies over 3 decades show
    higher nurse staffing associated with reduced
    mortality.
  • Recent longitudinal study found increases in RN
    staffing linked to lower mortality, with
    diminishing returns.
  • Most studies rely on hospital-wide measure of
    nurse staffing which may obscure relationship.

4
Hospital Responses to Price Competition
  • Hospital personnel increased from 1980s to early
    1990s.
  • RNs increased commensurate with volume and CMI
    while other nursing personnel declined.
  • Spetz (1999) found HMO penetration was not
    associated with RN staffing through early 1990s.

5
In summary
  • Substantial gaps in understanding of nurse
    staffingquality relationship.
  • Rely on crude staffing measures to explore
    relationship.
  • Lack information on current hospital responses to
    price competition.
  • 1999 California passes AB 394 to establish
    minimum nurse staffing ratios.

6
Research Questions
  • Are changes in nurse staffing levels associated
    with patient outcomes?
  • What hospital and market features are associated
    with staffing changes and thereby outcomes?

7
Study Design
  • California acute care hospitals, 1991-2001
  • Three AHRQ inpatient quality indicators
  • 30-day mortality for AMI, stroke, and hip fracture

8
Data
  • Californias Office of Statewide Health Planning
    and Development (OSHPD) discharge data from 1991.
  • OSHPD annual disclosure (financial) data
    1991-2001
  • State death certificates 1991-2001.
  • Sample
  • Hospitals n 421 short-term acute hospitals
  • (non-federal, non-Kaiser)
  • Patients
  • AMI n 352,536 (15.5)
  • Stroke n 592,651 (14.1)
  • Hip fracture n 276,628 (5.3)

9
Key Study Variables
  • Nurse staffing
  • RN, LVN, Nurse Aide
  • Nursing productive hours per patient day
  • Acute medical-surgical units
  • Market factors
  • HMO penetration for hospital market area (fixed
    radius)
  • High vs. low competition market areas

10
Control Variables
  • Age
  • Gender
  • Race
  • Ethnicity
  • Expected source of payment Medicare, Medicaid,
    uninsured, private
  • Elixhauser comorbidities
  • Hospital case-mix index
  • Year dummies 1991-2001 (1991 is reference)
  • Hospital fixed effects controls for
    time-invariant hospital and market factors

11
Model
  • Generalized linear model with hospital-level
    fixed effects time fixed effects

Model 1
Model 2
12
Hospital Summary Statistics
  • No. of hospitals 421
  • Avg. beds 192
  • Urban 88
  • Teaching 18.7
  • Ownership
  • Non-profit 52.7
  • Government 20.7
  • For-profit 26.6
  • Avg. CMI 1.114

13
Change in CM-adjusted RN medical-surgical hours
per patient day, 1991-2001
75th
25th
14
Effects of nurse staffing on 30-day mortality
Model AMI Stroke Hip Fracture
RN -0.004 (0.001) -0.002 (0.001) 0.002 (0.001)
LVN -0.003 (0.002) 0.0004 (0.001) 0.0008 (0.001)
Aide 0.001 (0.001) -0.0002 (0.0007) -0.0001 (0.0007)
RNbaseline 0.0004 (0.0002) -0.0001 (0.0001) -0.0004 (0.0003)
p lt .05 p lt .1
15
Effects of price competition on nurse staffing
HMO Penetration 2.479 (0.696)
HMO PenetrationHHI -3.192 (1.245)
p lt .001 p lt .01
16
Caveats/Limitations
  • Changes over time in DRGs, coding, zip codes (but
    smoothed/corrected to the extent possible)
  • Limited to California generalizable to other
    states?
  • Limited to mortality generalizable to other
    quality measures?
  • Are there thresholds to staffing-quality
    relationship?

17
Conclusions
  • Extent to which changes in RN staffing levels are
    associated with lower mortality varies by
    condition.
  • Increasing managed care penetration is associated
    with higher RN staffing except in most
    competitive markets.
  • Limiting the number of patients per nurse may
    improve quality outcomes.
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